ISPUB.

COM The Internet Journal of Hand Surgery

Volume 2 Number 1

Eccrine porocarcinoma of the hand: A Case Report

R Singh, S Majumder

Citation
R Singh, S Majumder. Eccrine porocarcinoma of the hand: A Case Report. The Internet Journal of Hand Surgery. 2007
Volume 2 Number 1.

Abstract

INTRODUCTION Figure 1
Ganglions and inclusion cysts of palms are a common Figure 1
presentation in clinical practice. Because of the functional
impairment and discomfort a palmar cyst can cause, patients
often seek help in the early stages of the disease.

However we present a case of a palmar swelling, cystic in

nature, which had been present for twenty eight years.
Subsequent surgical excision and histology proved an
altogether rarer pathology, an eccrine porocarcinoma.

CASE REPORT
A 73 year-old retired lady was referred from the accident
and emergency department for incision and drainage of a
suspected infected ganglion in the right palm. The swelling
had been present for over 28 years, and the patient attributed
its presence to repeated trauma in her job pushing trolleys at
a factory. Growth was insidious, reaching a final Figure 2
measurement of 3? x 2 inches[ fig 1,2,3], at which size it Figure 2
remained for 15 years. The cyst had become infected in the
24 hours prior to presentation, and was thought to be
exacerbated by a bump to the affected hand in the preceding
week.

In the past, the patients' GP had previously made a clinical

diagnosis of a ganglion but the patient had refused surgical
intervention. Co-morbidities included hypertension and diet-
controlled diabetes mellitus.

1 of 5
Eccrine porocarcinoma of the hand: A Case Report
On examination the lady had an infected cyst of
approximately 3? x 2 inches from the wrist crease to the
distal palmar crease. The cyst was not adherent to the
underlying tendons, clinically lying superficial to the palmar
fascia. There was no sign of any compression neuropathy.
Figure 3
Figure 3
Figure 4
Figure 4
In theatre, the cyst and the overlying skin was excised, the
cyst was found not to be adherent to the underlying palmar
fascia[fig 4,5,6] . The defect was covered with a split
thickness skin graft 2 days later when the infection had been
eradicated .
2 of 5
Figure 5
Figure 5
Figure 6
Figure 6
The wound healed well and there was no sign of local
recurrence or regional lymphadenopathy at review 4 months
following the surgery .
Histological analysis queried the cyst to be a proliferating
pilar cyst but finally confirmed the lesion to be a malignant
eccrine porocarcinoma .
Patient was reviewed in 3 months time and there was no
evidence of recurrence or lymphadenopathy.
A wider excision with 1 cm margins was done in view of the
diagnosis following discussion with the multi disciplinary
team comprising dermatologists pathologists, oncologists,
and the plastic surgeons .
Eccrine porocarcinoma of the hand: A Case Report
DISCUSSION
Eccrine porocarcinoma, first described in 1963 by Pinkus
and Mehregan [2], is a rare malignancy of the eccrine sweat
gland. Its incidence is less than 0.01% of all skin biopsy
specimens [6] and is more common in females. Some
malignancies have been reported as evolving from a benign
pre-existing poroma [3].
Eccrine porocarcinoma has been reported most frequently in
the lower extremities (44 %), with the remainder in the trunk
(24 %) and head (18 %). Only a few cases have been
reported in the upper extremities (8 %). A very small
proportion have been reported in the hand (3%) [3]. Despite
the density of sweat glands in the palm, there seems no
correlation with the distribution of eccrine porocarcinomas
[7].
The majority of malignant porocarcinomas' present clinically
as ‘verrucous plaque, polypoid growth, or an ulcerated lesion
of long duration.’[5]
A feature which may have confused the diagnosis in this
case was the cystic nature of the lesion as no other cases
reviewed in literature have been of cystic form.
The tumor is usually characterized by a history of long
duration , commoner in elderly population , and has no
particular sex predilection .
Conventional surgical resection , MOHS micrographic
surgery and radiotherapy have all been tried as treatment
options for primary and recurrent tumors . Metastatic tumors
have been treated with chemotherapy using 5 fluoro uracil
and hyper thermia ( Oudet Etal ) 9 , docetelal and interferon
alpha 2a and isoretinin ( Arslan )10 , and radiotherapy ( Da
Silva)11
The local recurrence rate is in the range of 11-25% (4, 12,13).
Lymph node metastasis occurs in 9.6-19%(12,3) . These data
suggest that malignant eccrine porocarcinoma though
potentially fatal has a better prognosis than previously
reported (12) . Important histological prognostic factors
include mitoses , lymphovascular invasion, and tumor depth
. (3)
The absence of any large clinical series makes it impossible
to determine the correct excision margins for the tumour and
also makes it difficult to determine if any adjuvant therapy
would be beneficial to the final outcome. The propensity for
local recurrence and metastasis does call for close
3 of 5
surveillance in the post operative period.
The case was discussed in the multidisciplinary team
meeting and it was agreed that a 1cm margin around the
tumor with excision of palmar fascia as the deep margin and
histo pathological examination of excised tissue to exculue
any residual tumor should be considered as a safe option .
Our patient had a history of a swelling of long duration and
the diagnosis was made only on histology .
Immuno histo chemical studies namely p53 protein
expression study , expression of angiotensin type 1 receptors
and expression of CEA , if possible should be done to
confirm the diagnosis .
The prolonged history did put us on the cautious consider if
the tumor had already metastasized but clinically there was
no evidence to suggest any metastatic disease . The
suggestion of malignant transformation in a benign cyst
could mean that the tumor was not malignant to begin with .
(Orella et al. [4] suggest that as many patients had a long
history before diagnosis, maybe this lesion arose in a
previously benign eccrine poroma).
CORRESPONDENCE TO
Rahul Singh Raj Nursing Home 23 A Park Road Allahabad
India 211001 0091 9451839940 E-mail:
singhrahul1975@gmail.com
References
1. Pinkus H, Rogin JR, Goldman P.Tumour exhibiting the
features of the epidermal sweat duct unit. Arch Dermatol,
1956; 74:511-21.
2. Pinkus H, Mehregan AH. Epidermotropic eccrine
carcinoma: a case combining features of eccrine poroma and
PagetÕs dermatosis. Arch Dermatol 1963; 88:597-607.
3. Robson A, Greene J, Ansari N, Kim B, Seed PT, McKee
PH, Calonje E. Eccrine porocarcinoma (Malignant Eccrine
Poroma), A clinicopathological study of 69 cases. Am J Surg
Pathol, 2001,25(6): 710-720
4. Orella JAL, Penalba AV, San Juan CC, Nadal RV,
Morrondo JC, Alvarez TT. Eccrine porocarcinoma- report of
nine cases. Dermatol Surg, 1997; 23:925-28.
5. Rana Roshani E , Verma Sachin Etal
Sweat gland tumor (eccrine porocarcinoma) of scalp :a rare
tumor
Indian journal of plastic surgery 2005 vol 38 iaase 1 pg 51
-53
6. Maeda T, Mori H , Matsuo T Etal . Malignant eccrine
porocarcinoma with multiple visceral metastasis : report of a
case with autopsy findings . J Clinical Pathology 1996 ; 53 :
566 - 70
7. A G Affleck , J L Bong etal
Eccrine porocarcinoma .
Dermatology online journal 12(1) : 17
8. Elder D, Elenitsas R, Ragsdale BD. Tumors of the
epidermal appendages. In: Elder D, Elenitsas R, Jaworsky C,
Eccrine porocarcinoma of the hand: A Case Report
Johnson B Jr, editors. Lever's Histopathology of skin. 8th ed.
Lippincott-Raven: Philadelphia; 1997. p. 747-803
9. Oudit D, Ellabban M, Vuppalapati G, Stringfellow H,
Korashi A. Porocarcinoma? Plast Reconstr Surg
2004;113:2216-7
10. Arslan E, Tatar C, Aksy A, Tutuner N. Denovo
malignant eccrine poroma of the nose: A review of the
midface as a location. Plast Reconstr Surg 2004;113:2227-9
11. Dasilva MF, Terek R, Weiss AP. Malignant eccrine
4 of 5
poroma of the hand. A case report. J Hand Surg
1997;22:511-4
12. Perna C, Cuevas J, Jimenez-Heffernan JA et al. Eccrine
porocarcinoma (malignant eccrine poroma). Am J Surg Path
2002; 26: 272-4.
13. Kacker A, Shaha AR. Ductal eccrine carcinoma arising
in the postaural area. Ear Nose Throat J. 1999
Aug;78(8):576-7.
Eccrine porocarcinoma of the hand: A Case Report

Author Information
R. Singh
Senior House Officer Plastic Surgery, Department of Plastic surgery, Pinderfields General Hospital

S. Majumder
Consultant Plastic and Hand Surgeon, Department of Plastic surgery, Pinderfields General Hospital

5 of 5